Prévention de l hypotension artérielle lors de la césarienne sous rachianesthésie (comparaison de deux degrés d inclinaison maternelle (décubitus latéral gauche 5 versus 10))

La rachianesthésie (RA) est la technique de référence pour les césariennes programmées. Son inconvénient est l hypotension artérielle maternelle. Parmi les mesures de prévention de ce risque, l inclinaison latérale gauche (ILG) de la table opératoire de 10, voire 15 est recommandée afin de lutter contre la compression aorto-cave par l utérus gravide. Parce que cette forte inclinaison peut gêner la parturiente et l opérateur, elle est souvent inférieure. Peu d études se sont intéressées à des dévers moindres dont l efficacité reste à démontrer. Nous avons donc comparé les ILG de 5 et 10. Soixante patientes ont été incluses dans cette étude prospective, randomisée, bicentrique. Les patientes étaient à terme, ASA 1 ou 2, et programmées pour une césarienne sous RA. Les patientes recevaient un pré-remplissage de 1000 ml de cristalloïde. Dés la fin de l injection intrathécale de bupivacaïne 10 mg, sufentanil 3 g, morphine 100 g (le temps initial t0), elles étaient installées avec une ILG de 5 ou 10 selon la randomisation. La pression artérielle systolique (PAS) était mesurée toutes les minutes de t0 à t10 puis toutes les 2 minutes de t10 jusqu à l extraction fœtale. En fonction des PAS aux différents temps, les patientes recevaient des bolus intraveineux d une association éphédrine + phényléphrine (3mg/ml + 15 g/ml) selon un algorithme prédéfini. L ILG de 10 versus 5, n a pas permis de diminuer l incidence d hypotension artérielle: 50% versus 47% (p=0.8). De plus, la dose totale de vasopresseurs (5,4 +- 4 vs 6,6 +- 5 ml) et les pH ombilicaux étaient comparables. Les résultats de cette étude suggèrent qu une ILG de 5 est aussi efficace qu une ILG de 10 pour la prévention de l hypotension artérielle maternelle et de ses conséquences fœtales lors de la RA pour césarienne programmée.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

OCOSO2: study protocol for a single-blinded, multicentre, randomised controlled trial assessing a central venous oxygen saturation-based goal-directed therapy to reduce postoperative complications in high-risk patients after elective major surgery

International audienceAbstract Background Fluid loading-based goal-directed therapy is a cornerstone of anaesthesia management in major surgery. Its widespread application has contributed to a significant improvement in perioperative morbidity and mortality. In theory, only hypovolemic patients should receive fluid therapy. However, to achieve such a diagnosis, a surrogate marker of cardiac output adequacy must be used. Current methods of fluid loading-based goal-directed therapy do not assess cardiac output adequacy. Nowadays, new devices make it possible to continuously monitor central venous oxygen saturation (ScvO 2 ) and therefore, to assess the adequacy of perioperative cardiac output during surgery. In major surgery, ScvO 2 -based goal-directed therapy can be used to enhance fluid therapy and improve patient outcomes. Methods We designed a prospective, randomised, single-blinded, multicentre controlled superiority study with a 1:1 allocation ratio. Patients to be included will be high-risk major surgery patients (> 50 years old, ASA score > 2, major intra-abdominal or intra-thoracic surgery > 90 min). Patients in the control group will undergo standard fluid loading-based goal-directed therapy, as recommended by the guidelines. Patients in the intervention group will have ScvO 2 -based goal-directed therapy and receive fluid loading only if fluid responsiveness and cardiac output inadequacy are present. The primary outcome will be the Comprehensive Complication Index on day five postoperatively. Discussion This study is the first to address the issue of cardiac output adequacy in goal-directed therapy. Our hypothesis is that cardiac output optimisation during major surgery achieved by continuous monitoring of the ScvO 2 to guide fluid therapy will result in a reduction of postoperative complications as compared with current goal-directed fluid therapy practices. Trial registration ClinicalTrials.gov. NCT03828565. Registered on February 4, 2019

Impact of a computer-assisted decision support system (CDSS) on nutrition management in critically ill hematology patients: the NUTCHOCO study (nutritional care in hematology oncologic patients and critical outcome)

International audienceBackground: Mortality of critically ill hematology (HM) patients has improved over time. Thus, those patients require an extensive diagnostic workup and the optimal use of available treatments. There are no data regarding nutrition strategy for critically ill HM patients, while nutritional support is crucial for both HM and critically ill patients. We hypothesized that the implementation of a computer-assisted decision support system (CDSS), designed to supervise a nutritional intervention by a multidisciplinary team, would be able to increase guidelines adherence and outcomes. Results: In this before/after study, 275 critically ill hematology patients admitted to the ICU over 5-year period were included. Energy and protein intakes were delivered using standard protocol in the 147 patients (53%) of the 'before group' and using a CDSS in order to reach every day predefined caloric and protein targets accordingly to the cata-bolic or anabolic status in the 128 patients (47%) of the 'after group. ' Using a Poisson regression, we showed that the use of CDSS allowed to reach a relative increase in the rate of days in compliance with caloric (1.57; 95% confidence interval (CI), [1.17-2.10], p = 0.0025) and protein targets (3.86 [2.21-6.73], p < 0.0001) in the 'after group' by more than 50% as compared with the 'before group. ' Interestingly, compliance rates were low and only reached 30% after intervention. Hospital mortality, ICU-acquired infection, and hospital, and ICU length of stay were similar in the two groups of patients. Importantly, exploratory analysis showed that hospital mortality was lower in the 'after group' for neutro-penic and severely ill patients. Conclusion: For critically ill hematology patients, the use of a nutritional CDSS allowed to increase the days in compliance with caloric and protein targets as compared with no CDSS use. In this context, overall hospital mortality was not affected. © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made

Additional file 1 of OCOSO2: study protocol for a single-blinded, multicentre, randomised controlled trial assessing a central venous oxygen saturation-based goal-directed therapy to reduce postoperative complications in high-risk patients after elective major surgery

Additional file 1

Processus d'annotation dans les documents pour l'action : textualité et médiation de la coopération

International audienceThis chapter deals with digital documents used as a medium for collective practices. Documents of this kind are hyper- fragmented because they are authored at a different time (weblog) and even by different people (wiki). But these fragments are also massively linked to one another (“semantic web” in a broad sense). In the beginning of this chapter, a theoretical framework is given with the notions of document for action and annotation. Then, a state of the art is given in several domains: medical care, design in mechanics, design of open source software, scholarly documentation.Ce chapitre traite des documents numériques utilisés comme supports à une pratique collective. Ces documents se caractérisent à la fois par une hyper-fragmentation résultant d’une hétérogénéité temporelle (weblog) et auctoriale (wiki) mais aussi par une multiplication des relations explicites entre ces fragments (« web sémantique » au sens large). Le chapitre propose tout d’abord un cadre théorique autour des notions de document pour l’action et d’annotation pour ensuite analyser l’état des recherches dans différents domaines d’application : médecine, conception mécanique, conception de logiciels libres, documentation scientifique

Processus d'annotation dans les documents pour l'action : textualité et médiation de la coopération

International audienceThis chapter deals with digital documents used as a medium for collective practices. Documents of this kind are hyper- fragmented because they are authored at a different time (weblog) and even by different people (wiki). But these fragments are also massively linked to one another (“semantic web” in a broad sense). In the beginning of this chapter, a theoretical framework is given with the notions of document for action and annotation. Then, a state of the art is given in several domains: medical care, design in mechanics, design of open source software, scholarly documentation.Ce chapitre traite des documents numériques utilisés comme supports à une pratique collective. Ces documents se caractérisent à la fois par une hyper-fragmentation résultant d’une hétérogénéité temporelle (weblog) et auctoriale (wiki) mais aussi par une multiplication des relations explicites entre ces fragments (« web sémantique » au sens large). Le chapitre propose tout d’abord un cadre théorique autour des notions de document pour l’action et d’annotation pour ensuite analyser l’état des recherches dans différents domaines d’application : médecine, conception mécanique, conception de logiciels libres, documentation scientifique

Effect of non-invasive ventilation after extubation in critically ill patients with obesity in France: a multicentre, unblinded, pragmatic randomised clinical trial

International audienc